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1 From the Departments of Nutrition Sciences and Medicine, University of Alabama at Birmingham
2 Presented at the symposium "An Evidence-Based Approach to Medical Nutrition Education," held at Experimental Biology 2005 in San Diego, CA, 2 April 2005. 3 Supported by the American Board of Physician Nutrition Specialists. 4 Reprints not available. Address correspondence to DC Heimburger, 1675 University Boulevard, Webb 439, Birmingham, AL 35294-3360. E-mail: dheimbur{at}uab.edu.
ABSTRACT
A significant obstacle to nutrition literacy among physicians is a paucity of Physician Nutrition Specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula and who can serve as role models for incorporating nutrition into patient care. To address these issues, the Intersociety Professional Nutrition Education Consortium developed a paradigm for PNSs that is designed attract more physicians into the field; promulgated educational standards for fellowship training of PNSs; and established a unified mechanism for certifying PNSs, the American Board of Physician Nutrition Specialists (ABPNS). This article details the consensus paradigm and specific training standards and outlines the features and history of the ABPNS. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Certification is equally accessible to physicians with backgrounds in any of the specialties relevant to clinical nutrition. It is hoped that more physicians will identify nutrition as a specialty interest if training opportunities are available in a variety of settings and are merged with their other professional interests. ABPNS invites input and feedback from colleagues around the world.
Key Words: Training • certification • Physician Nutrition Specialists
INTRODUCTION
Although it is widely agreed that the training of physicians should include a focus on the relations of diet to disease, the teaching of nutrition in medical schools and residency programs is often inadequate. Many physicians thus remain insufficiently informed about the role of diet in the prevention and treatment of disease. A significant obstacle to nutrition literacy among physicians is a paucity of Physician Nutrition Specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula and who can serve as role models for incorporating nutrition into patient care.
To encourage the American professional nutrition societies to unite in addressing these issues, the Intersociety Professional Nutrition Education Consortium (IPNEC) was founded in 1997. The objectives of the IPNEC were to develop a paradigm for PNSs that may attract more physicians into the field; to promulgate educational standards for fellowship training of PNSs; and to establish a unified mechanism for certifying PNSs. The first 2 of these goals were completed between 1997 and 2001 and the latter goal was accomplished with the establishment of the American Board of Physician Nutrition Specialists (ABPNS) in 2001. The ABPNS registered and owns rights to the term Physician Nutrition Specialist, so that only its diplomates may use this title.
PARADIGM FOR PHYSICIAN NUTRITION SPECIALISTS
IPNEC developed and promulgated the following paradigm for PNSs to encourage growth in the number of nutrition training programs and in the number of physicians who pursue nutrition training.
A PNS is a physician with training in nutrition who devotes a substantial career effort to nutrition and who can assume a leadership role in coordinating interdisciplinary clinical nutrition services and education in academic health centers, other medical centers, private practice, and other health care settings. PNSs generally have backgrounds in the specialties of internal medicine, pediatrics, family medicine, or general surgery, and sometimes in subspecialties such as adult or pediatric gastroenterology, endocrinology, critical care, nephrology, cardiology, or others. They have completed a period of defined nutrition training (6 mo), in addition to categorical residency training, that includes mastery of a defined core of knowledge and completion of a period of mentored clinical nutrition experience, which may be obtained in a nutrition fellowship or as part of training in another subspecialty.
This paradigm recognizes that physicians who specialize in nutrition come from a variety of backgrounds and do not all follow the same track into the field or share exactly the same major interests, and yet there exists a body of knowledge and expertise common to all PNSs. It is hoped that more physicians will identify nutrition as a specialty interest if training opportunities are available in a variety of settings and are merged with their other professional interests (eg, gastroenterology or endocrinology).
CURRICULUM TEMPLATE FOR TRAINING PHYSICIAN NUTRITION SPECIALISTS
IPNEC used a national role delineation survey to develop consensus training standards for PNSs by using the format of the AMA Graduate Medical Education Directory, as detailed below.
Eligibility for training
To be eligible to enter fellowship training in the subspecialty of clinical nutrition, a physician must have completed categorical residency training. Although this is generally in pediatrics, internal medicine, family medicine, or general surgery, physicians with other training backgrounds may be included. Elective schedules permitting, physicians who are enrolled in fellowship programs in subspecialties such as adult or pediatric gastroenterology, endocrinology, critical care, nephrology, or cardiology may pursue nutrition training integrated within their major subspecialty fellowship program.
Program requirements for fellowship education in clinical nutrition
I. Educational program
Subspecialty education programs in clinical nutrition must provide training and experience at a level sufficient for the fellow to acquire competency as a specialist in the field. Training must comprise 6 mo of mentored clinical experience and formal instruction, either as a block or as an equivalent amount of time (1000 h) integrated among other duties over a longer time period. No less than 20% of the clinical experience should be gained in inpatient settings and no less than 20% in outpatient settings (eg, 1 d/wk over 6 mo or 0.5 d/wk over 12 mo).
II. Facilities and resources
Modern facilities and services, including inpatient, ambulatory care, and laboratory resources, must be available and functioning. There should be a complete biochemistry laboratory, interdisciplinary nutrition support service, indirect calorimetry equipment, body-composition facility, dietary service, and medical and surgical intensive care units.
III. Specific program content
A. Clinical experience.
1) The training program must provide opportunities for fellows to develop clinical competence in the field of clinical nutrition.
2) Clinical experience must include opportunities to observe and manage a sufficient number of new and follow-up inpatients and outpatients of all ages, including children and older adults; of both sexes; and with a wide variety of common and uncommon nutrition-related disorders. The clinical experience must be supervised by physicians, and an interdisciplinary team, such as a nutrition support service, that includes registered dietitians or other appropriate health care professionals must provide care. The program must include opportunities to function in the role of a clinical nutrition consultant for other physicians and services in both inpatient and outpatient settings.
3) Fellows should have formal instruction, clinical experience, or opportunities to acquire expertise in the evaluation, nutritional management, and prevention of the following disorders: malnutrition, obesity and eating disorders, diabetes mellitus, hypertension and cardiovascular diseases, dyslipidemias, gastrointestinal and liver disorders, cancer, renal disorders, osteoporosis, hematologic disorders, pulmonary disorders, and immune disorders (eg, HIV disease and transplantation).
4) Fellows should have formal instruction, clinical experience, or opportunities to acquire expertise in the evaluation, management, and prevention of the following clinical problems: stress states, hypometabolic and starvation states, refeeding syndrome, drug-nutrient interactions, fluid and electrolyte management, interpretation of laboratory values, and nutritional access device problems.
B. Technical and other skills.
The program must provide for instruction in the indications, contraindications, complications, limitations, and, where applicable, interpretation of the following diagnostic and therapeutic techniques and procedures: nutritional assessment (history including diet, physical examination, and laboratory interpretation), methods for assessing energy expenditure and body composition, dietary counseling, feeding devices, and enteral and parenteral nutrition support in both inpatient and outpatient settings.
C. Formal instruction.
The program must, as a minimum, ensure that fellows receive formal instruction in the following listed areas (this instruction may be in the form of lectures, conferences, seminars, or formal self-study programs or in other settings or locations, including previous or concomitant dietetic or graduate training in nutrition): 1) nutritional assessment, interventions, and therapies, including complementary and alternative nutrition therapies; 2) macro- and micronutrients in health and disease, including metabolism, absorption, and utilization and the signs, symptoms, and management of deficiencies and excesses; 3) nutrition through the life cycle; 4) health promotion and disease prevention; and 5) ethical issues in nutrition.
NUTRITION CURRICULUM GUIDE
IPNEC also used the results of the role delineation survey to develop a comprehensive Curriculum Guide that suggests instructional materials necessary to train PNSs. The guide is located on IPNEC's website, where it can be accessed free of charge (Internet: www.ipnec.org/guide). It is updated periodically. It includes suggestions of existing textbooks and chapters, review articles, original reports, seminal papers, case studies, mediated materials, and websites in all the content areas contained in the curriculum template. It was not considered necessary or desirable to write new curricular materials (articles, books, etc), because a wealth of these exists. Rather, the guide's intent is to point trainees to the best available resources in each content area. Also, although the guide is intended to be a relatively complete resource, it is by no means exhaustive, and many very worthy resources could not be listed.
ABPNS CERTIFICATION
IPNEC established the ABPNS (Internet: www.ipnec.org/abpns) in 2001 to provide a credential that recognizes physician expertise in clinical nutrition. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Its constituency is defined by the paradigm for PNSs outlined above. Certification is equally accessible to physicians with backgrounds in any of the specialties relevant to clinical nutrition, as described above. Physicians are eligible to take the examination if they hold a current US medical license and ABMS primary board certification; physicians who hold equivalent credentials in other countries are also eligible. During the first 5 y in which it was offered (2001–2005), physicians could take the ABPNS examination without having completed specific training in nutrition. Beginning with the 2006 examination, candidates will be required to document 6 mo of training in clinical nutrition, either as part of a fellowship in a related subspecialty or as a freestanding nutrition fellowship.
The ABPNS Certification Examination for Physician Nutrition Specialists is given annually in November. It contains up to 250 multiple-choice, objective questions encompassing the full breadth of clinical nutrition, as reflected in the IPNEC Curriculum Guide. The examination content is weighted as follows: general aspects of nutrition, 15%; nutrients (macro- and micro-), 20%; nutrition status assessment, 10%; disease-specific nutrition, 40%; and enteral & parenteral nutrition support, 15%. The pass rate has been 70% to 75%. The examination fee is $600. It is offered in 20–25 sites throughout North America and in overseas locations on request. The certificate is valid for 10 y, after which recertification is required to keep it current.
As of 2005, the ABPNS has 221 diplomates, approximately one-half of whom indicated that they completed some fellowship training in nutrition. One-half of these fellowships were indicated as stand-alone nutrition fellowships and one-half were combined with other subspecialties. Most of the diplomates are in clinical practice.
To secure broad and sustained investment and ownership of the credentialing process, permanent membership on the ABPNS Board of Directors was established for 6 national nutrition societies that have significant physician memberships. The composition of the current Board of Directors is shown in Table 1.
View this table:
TABLE 1. American Board of Physician Nutrition Specialists (ABPNS) member societies and 2006 Board of Directors
COMMUNICATION
IPNEC and ABPNS desire to communicate with the medical nutrition community to achieve broad consensus and to expand the discipline of clinical nutrition. They have disseminated information about their rationale and activities through their website (Internet: www.ipnec.org) and links on their member societies' websites, brochures, presentations and networking at national and international meetings, and publications (1, 2). The website includes the IPNEC Curriculum Guide, a handbook for ABPNS Candidates, an application to take the examination, and methods for contacting ABPNS. It includes information on available nutrition fellowships, including links to the fellowship programs' websites when they exist, that was collected from a survey conducted in conjunction with the American Society for Clinical Nutrition's Committee on Professional Nutrition Education. It also contains information about all ABPNS diplomates for the benefit of PNSs, the public, and other interested parties.
ABPNS now particularly invites input and feedback from colleagues around the world. The board would like to add membership from one or more clinical nutrition societies in other countries.
ACKNOWLEDGMENTS
DCH was responsible for compiling and reporting the information contained in this article and submitted it on behalf of himself and the ABPNS Board of Directors, who reviewed and approved the manuscript.
The author had no conflicts of interest to report.
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